Blog | Thursday, January 21, 2010

Patient-Driven Primary Care Shouldn't be Labeled "Concierge"


This post by Alan Dappen, MD, appeared originally at Better Health.

I bristle when my patient-driven, fee-for-service primary practice, DocTalker Family Medicine, gets lumped into the "concierge" movement, as it frequently does. First, veterinarians, accountants, mechanics lawyers and all other service providers in everyday life who work directly for their clients and not as "preferred providers" for the insurance companies are not labeled "concierge." Secondly, the label "concierge" implies exclusivity, membership, high yearly retainers, and capped patient enrollment. Each of these labels we too reject.

A practice like ours out-competes the traditional model and the "concierge idea" in almost every measurable way: access, convenience, patient control, speed to treatment, quality and finally and maybe most importantly for the sake of the health care debate, price. Our boss is each patient, one at a time, and our goal is to provide the most cost effective delivery model achievable. We strive for nothing less than making primary care immediate, high quality, patient-controlled and affordable to every American. We deliver a concierge-level service at a price that is much less than even the price-fixing controlled by the insurance-driven model to date.

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Central to our philosophy is how we approach payment. What we sell is time; we charge purely on time-based services. Prices for materials, like supplies, vaccines, and labs are posted on the website and have little mark-up so that we can pass on the savings to our patients. Everyone who interferes with patient control, causes a conflict of interest, or increases cost has been dismissed from the relationship. This includes insurance companies, Medicare, data-miners, coders and drug reps. Our patients pay when services are rendered, just like any other services purchased in our lives.

We applaud concierge practices for providing VIP-service that all patients deserve: immediate access to a practitioner, convenience, and personalized and high quality care. We offer the same high level of service, but with key differences:

No rationing of care by price. Unlike the concierge philosophy, there is no access fee, which in many concierge practices can total $1,500 per year. We instead sell time. We charge in five-minute increments of time since it's the most transparent and policeable way of measuring our productivity. Our patients have a choice to pay-as-they-go, which means that they pay when service has been rendered, ($33.33 for five minutes) be it a phone call, 10-minute office visit, 10-minute e-mail or 10-minute videoconference, no matter what time of day or day of the year. We do offer a 25% discount to patients who put money in a pre-paid account, which means that patients can pay for service ahead of time, and will use the time when they need it. These pre-paid patients have a discounted rate of $25 for every 5 minutes. Patients can close their accounts with us at any time at no penalty.

The average person needs about an hour of care a year, meaning they have 24-7 instant access to us for $300 per year. Over 50% of interactions are solved through phones and e-mails. About 75% of the patients in our system spend less than $300 in a year. Fewer than 1% of our patients this year (out of an active patient group 3000) spent over $ 1,500 and most of these people are elderly, trapped at home with significant medical problems. We are the only medical practice left in Fairfax and Arlington County, Va. (combined population of 1.3 million) that offers house calls. This gives you an idea of the price difference that we have over the concierge and even the typical business model of care.

No exclusivity or capping of patient numbers. Our philosophy and business model is based on a volume business. We estimate that each medical provider in the practice must carry a work load of about 2,000 active patients to make a competitive living. We do not limit the number of patients we will take. When we need to add on a new primary care physician (PCP) to accommodate new patients, we do. Our satisfaction comes from the mission of providing excellent care at an excellent price and eliminating all conflicts of interest that arise between the doctor and patient that either undermine the relationship or increase the cost of the service.

Helping to solve the primary care crises. PCPs are in short supply. There are not enough of us to go around and more retiring faster than they are being made. Medical schools fail to attract primary care specialists in any large numbers since the field typically promises soul-crushing workloads and frustrations in reimbursement, which rapidly leads to high burnout. One of the directions the burned-out physician heads is towards the concierge model. By most definitions the concierge solution is a solution for the doctor.

The concierge model places a premium price on access to primary care, taking advantage of the shortage of primary care physicians. I predict this is not sustainable. The typical concierge practitioner collects $1 million in access fees from clients and takes care of 600-800 patients, which totals 25-33% of capacity in a typical practice where physicians are expected to care for 2,000 to 2,500 patients. Under the concierge banner, primary care costs three to five times more than needed; it would also require a primary care work force three times larger than it is today.

I understand that our practice seems a little radical, but some call us "the practice of the future." In truth, it's how medicine used to be practiced only a few decades ago. Likewise, or practice embodies the medical home described by many who believe in the key role primary care needs to play in our health care system. To make this happen, we've upgraded phones, emails, video, computers , the electronic medical records and direct communications between patient and doctor into the practice and linked it to time-based billing like most other sectors of the economy.
My partners and I hope that others with the same hopes and goals for primary care will consider this model or something like it soon. The future of primary care depends on it, and doctors are the solution.

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.